Method of implanting a modular fracture fixation system

ABSTRACT

A fracture fixation plate system for use on a long bone having a metaphysis and a diaphysis, includes at least one end plate having a head portion for the metaphysis, and at least one diaphyseal plate having a first end and a second end with a plurality of screw holes therebetween. The end plate includes mating structure adapted to mate with and securely couple to at least one end of the at least one diaphyseal plate. The system preferably includes several end plates and diaphyseal plates to accommodate anatomy of various sizes.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. Ser. No. 11/536,441, filed Sep.28, 2006, which is hereby incorporated by reference herein in itsentirety.

This application is related to U.S. Ser. No. 11/378,703, filed Mar. 17,2006 and U.S. Ser. No. 11/082,401, filed Mar. 17, 2005, both of whichare hereby incorporated by reference herein in their entireties. U.S.Ser. No. 10/985,598, filed Nov. 10, 2004, now issued as U.S. Pat. No.7,635,381, U.S. Ser. No. 11/040,779, filed Jan. 21, 2005, and U.S. Ser.No. 11/466,905, filed Aug. 24, 2006, now issued as U.S. Pat. No.7,604,657, are hereby incorporated by reference herein in theirentireties.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates broadly to surgical implants. More particularly,this invention relates to a bone fracture fixation system.

2. State of the Art

Fracture to the metaphyseal portion of a long bone can be difficult totreat. Improper treatment can result in deformity and long-termdiscomfort.

Alignment and fixation of a metaphyseal fracture (occurring at theextremity of a shaft of a long bone) are typically performed by one ofseveral methods: casting, external fixation, pinning, and plating.Casting is non-invasive, but may not be able to maintain alignment ofthe fracture where many bone fragments exist. Therefore, as analternative, external fixators may be used. External fixators utilize amethod known as ligamentotaxis, which provides distraction forces acrossthe joint and permits the fracture to be aligned based upon the tensionplaced on the surrounding ligaments. However, while external fixatorscan maintain the position of the wrist bones, it may nevertheless bedifficult in certain fractures to first provide the bones in properalignment. In addition, external fixators are often not suitable forfractures resulting in multiple bone fragments. Pinning with K-wires(Kirschner wires) is an invasive procedure whereby pins are positionedinto the various fragments. This is a difficult and time consumingprocedure that provides limited fixation if the bone is comminuted orosteoporotic. Plating utilizes a stabilizing metal plate placed againstthe bone, and screws extending from the plate into holes drilled in thebone fragments to provide stabilized fixation of the fragments.

In some cases, a relatively proximal diaphyseal portion as well as thedistal metaphyseal portion of the radius may be fractured. Similarly, arelatively distal diaphyseal portion as well as the proximal portion ofthe humerus may be fractured. In these cases, diaphyseal plates areoften used in conjunction with an appropriate metaphyseal plate. Thereis a disadvantage, however, in using two separate plates rather thanone. It results in unsupported bone between the two plates. Theresultant load is supported by the bone between the plates in aconcentrated manner. Thus, it would be desirable to provide anintegrated plate that shares the load across the entire implant for bothmetaphyseal and diaphyseal fractures.

U.S. Pat. No. 5,190,544 to Chapman et al. describes a modular platingsystem including a metaphyseal plate and a diaphyseal plate that areinterconnected via a dovetail slot and then secured to the bone withcortical bone screws to lock the plates together. The integrity of sucha system is subject to loosening in the event the bone screws loosentheir engagement with the bone, e.g., through micromotion. Furthermore,if the bone is of poor quality, e.g., as a result of multiple fracturesalong the bone portion underlying the components, integrity between thecomponents may never be accomplished. In addition, the metaphysealcomponent which receives an end of the diaphyseal plate is significantlythicker (approximately 75% percent thicker) and wider (approximately 35%wider) than the diaphyseal plate, providing an undesirably thickmetaphyseal plate and creating a potentially irritating transition intwo dimensions from the metaphyseal plate to the diaphyseal plate wherethe metaphyseal plate ends.

SUMMARY OF THE INVENTION

It is therefore an object of the invention to provide a modular fixationsystem.

It is another object of the invention to provide a modular fixationsystem that desirably aligns and stabilizes multiple bone fragments in afracture to permit proper healing.

It is also an object of the invention to provide a modular fixationsystem that does not rely on the bone for locking the modular componentstogether.

It is a further object of the invention to provide a modular fixationsystem in which the components are coupled together in a very stablemanner to effect a rigid assembly.

It is yet another object of the invention to provide a modular fixationsystem that, in view of manufacturing variations, will eliminate playbetween coupled components to increase the load transfer between thecoupled components.

It is a yet a further object of the invention to provide a modularfixation system that will not irritate the tissue.

It is an additional object of the invention to provide improved fixationsystems that accommodate the anatomical structure of the metaphysis anddiaphysis of the radius and humerus.

In accord with these and other objects, which will be discussed indetail below, various embodiments of a modular fracture fixation systemare provided. The modular system of the invention is described withrespect to exemplar embodiments specifically adapted for the radius andhumerus bones.

In exemplar embodiments for the radius bones, the modular fracturefixation system includes a plurality of different sized distal radiusplates (e.g., volar plates or dorsal plates) and a plurality ofdifferent sized diaphyseal plates. The distal radius plates aregenerally T-shaped having a head and a stem substantially transversethereto. The end of the stem is provided with a mating structure wherebyan end of a diaphyseal plate can be coupled to the distal radius plate.The surgeon can select an appropriate size distal radius plate and anappropriate size diaphyseal plate and secure them together prior toimplantation on the bone to form a unified distal radius and diaphysealplate customized for the patient. This overcomes the disadvantage ofusing separate distal radius and diaphyseal plates and allows for a widevariety of different sizes while using the minimum number of components.It is an important aspect of the invention that the distal radius plateand diaphyseal plate be joined without reliance on the bone to jointhem. Otherwise, the tight interface and coupling between the platescould be compromised based on the quality of the bone, which may befractured beneath the location of the coupling or which may beosteoporotic. In order to secure the distal radius plate and diaphysealplate together independent of the bone, set screw holes are provided atboth ends of the diaphyseal plates. In addition, suitable matingstructure is provided at the end of the radius plate stem including anon-threaded set screw hole and an intersecting socket. The two platesare mated by inserting one end of the diaphyseal plate into the socketof the distal radius plate stem, then inserting one or more connectionset screws through the non-threaded screw hole(s) in the stem to engagethe threaded set screw hole in the end of the diaphyseal plate. Incertain embodiments, means are provided to eliminate any play betweenthe plates, including posts, flats, and non-circular holes, and multipleset screw holes and connection set screws may be provided.

In exemplar embodiments for the humerus bones, the modular fracturefixation system includes a plurality of different sized proximal humerusplates and a plurality of different sized humeral diaphyseal plates. Thehumeral plates have a head portion, preferably provided with a pluralityof threaded holes and suture holes, and a stem portion provided withlongitudinally displaced screw holes. The end of the stem is providedwith a mating structure whereby an end of a diaphyseal plate can becoupled to the humeral plate. The surgeon can select an appropriate sizehumeral plate and an appropriate size diaphyseal plate and secure themtogether prior to implantation on the bone to form a unified humeralplate customized for the patient. This overcomes the disadvantage ofusing separate plates for the metaphyseal and diaphyseal portions of thehumerus and allows for a wide variety of different sizes while using theminimum number of components. For reasons advanced above, it is animportant aspect of the invention that the proximal humerus plate anddiaphyseal plate be joined without reliance on the bone to join them. Ina coupling system similar to the radius system, mating structure isprovided at the end of the humerus plate stem including a non-threadedscrew hole and an intersecting socket. The two plates are mated byinserting one end of the diaphyseal plate into the socket of the platestem, then inserting one or more connection set screws through thenon-threaded screw holes in the stem to engage the threaded set screwhole in the end of the diaphyseal plate. Preferably, means are providedto eliminate any play between the plates, and multiple connection screwholes and connection screws may be provided.

Additional objects and advantages of the invention will become apparentto those skilled in the art upon reference to the detailed descriptiontaken in conjunction with the provided figures.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a top perspective view of a distal radius volar plateaccording to the invention;

FIG. 2 is a bottom perspective view of the volar plate;

FIG. 3 is top perspective view of a diaphyseal plate according to theinvention;

FIG. 4 is an enlarged broken bottom perspective view of an end of thediaphyseal plate;

FIG. 5 is an enlarged broken top perspective view of an end of thediaphyseal plate;

FIG. 6 is a top perspective view of the volar plate with the diaphysealplate inserted into the slot at the end of the volar plate stem;

FIG. 7 is an enlarged broken top perspective view showing the mating ofthe volar plate and the diaphyseal plate with a set screw;

FIG. 8 is an enlarged perspective view of the set screw;

FIG. 9 is a perspective view of a second embodiment of a modular platesystem according to the invention;

FIG. 10 is a broken bottom perspective view of the embodiment of FIG. 9;

FIG. 11 is a broken top perspective exploded view of the embodiment ofFIG. 9;

FIG. 12 is a broken bottom perspective exploded view of the embodimentof FIG. 9;

FIG. 13 is a broken top view of the embodiment of FIG. 9;

FIG. 14 is a section view across line 14-14 in FIG. 13;

FIG. 15 is a perspective view of a third embodiment of a modular platesystem according to the invention;

FIG. 16 is a broken bottom perspective view of the embodiment of FIG.15;

FIG. 17 is a broken top perspective exploded view of the embodiment ofFIG. 15;

FIG. 18 is a broken bottom perspective exploded view of the embodimentof FIG. 15;

FIG. 19 is a broken top view of the embodiment of FIG. 15;

FIG. 20 is a section view across line 20-20 in FIG. 19;

FIG. 21 is a broken top view of a fourth embodiment of a modular platesystem according to the invention;

FIG. 22 is a broken section view along line 22-22 in FIG. 21;

FIG. 23 is a top view of the modular connection of the fourthembodiment, illustrated by the removal of material along line 23-23 inFIG. 22;

FIG. 24 is a top perspective view of a diaphyseal plate for a fifthembodiment of the invention;

FIG. 25 is a bottom perspective view of a metaphyseal proximal humeralend plate for modular assembly with the diaphyseal plate of FIG. 24;

FIG. 26 is a perspective longitudinal section view of the preliminarymodular assembly of the plates shown in FIGS. 24 and 25;

FIG. 27 is a broken bottom view of the preliminary modular assembly ofFIG. 26;

FIG. 28 is a broken bottom view of the modular assembly of the platesshown in FIGS. 24 and 25; and

FIG. 29 is a perspective longitudinal section view of the modularassembly of the plates shown in FIGS. 24 and 25 with additionalfasteners.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

Turning now to FIGS. 1 and 2, a distal radius volar fixation plate (orgenerally any ‘end’ plate or metaphyseal plate) 10 includes a distalhead portion 12 and a proximal stem portion 14. In a preferredembodiment, the plate 10 corresponds to the plate described inpreviously incorporated U.S. Ser. No. 10/985,598. However, othermetaphyseal plates for different locations on the radius bone or evenfor placement on different bones can be used.

The head portion 12 of the volar fixation plate 10 shown has a pluralityof alignment holes 16 which are dimensioned to closely accept K-wires ina fixed angle relationship and two longitudinally offset rows 17 a, 17 bof screw holes 18 for receiving fixation elements therethrough. In apreferred embodiment, the screw holes 18 are threaded, and as such arespecifically adapted to receive locking screws and/or pegs that lock inaxial alignment relative to the plate.

The stem portion 14 has at least one alignment hole 20 dimensioned toclosely accept a K-wire and may optionally include one or more (two asillustrated) bone screw holes 22, 24. That is, the stem may besubstantially shorter than shown and does not need to include a bonescrew hole. The free end of the stem portion 14 includes a socket in theform of a slot 26 (for receiving an end of the diaphyseal plate 40,described below) and an orthogonal set screw hole 28 intersecting theslot. As shown in FIGS. 1-8, the slot 26 is open to the proximal end ofthe stem portion, and preferably is also open on the bottom side of thestem portion as well.

From FIGS. 1-8, it will be appreciated that the top side (FIG. 1) of thevolar plate 10 has a topography of curved surfaces and recessessurrounding some of the holes to provide a low profile when seated onthe anatomical bone surface. The bottom side (FIG. 2) of the headportion 12 is likewise constructed to conform to the anatomy, while thestem portion 14, however presents a smooth surface. The bottom of thehead portion 12 lies in a first plane and the stem portion 14 lies in asecond plane. A neck 30 transitions between the two planes. The anglebetween the two planes is preferably approximately 25 degrees.

The alignment holes and the bone screw holes are used as described inpreviously incorporated U.S. Ser. No. 10/985,598. The slot 26 and theset screw hole 28 are used in conjunction with a diaphyseal plate and aset screw as described in more detail below.

Turning now to FIGS. 3-5, an exemplary diaphyseal plate (or fragmentplate) 40 according to the invention is illustrated. The diaphysealplate 40 is an elongate plate having a first end 42 and a second end 44.A plurality of bone screw holes 46, 48, 50, 52, 54, 56 are spaced alongthe length of the plate for receiving bone screws, and a threaded setscrew hole 58, 60, 62, 64, 66, 68 is arranged adjacent each bone screwhole. More particularly, such screw holes are preferably any of thescrew holes and associated locking systems described in U.S. Pub. No.20050187551 A1, incorporated by reference herein, for the reasons andadvantages provided therein, although any suitable bone screw hole maybe used.

As illustrated, the shape of the diaphyseal plate 40 and the arrangementof holes are preferably longitudinally symmetrical about a mid point 70.Each set screw hole is provided on a side of a bone screw hole closer toan end of the diaphyseal plate than the midpoint of the plate, with aset screw hole 58, 68 specifically being located at each end of theplate. As seen best in FIGS. 4 and 5, the ends 42, 44 of the plate aretapered as well as rounded. The taper occurs over a significant lengthwhich permits both a bone screw hole 46, 56 and a set screw hole 58, 68to be located in the tapered ends 42, 44 of each plate. Comparing FIGS.4 and 5 with FIGS. 1 and 2, it will be appreciated that the ends 42, 44of the plate 40 are shaped and dimensioned to fit neatly into the slot26 of the volar plate 10 with the set screw hole 58, 68 of the plate 40aligning with the set screw hole 28 of the plate 10. This is illustratedmore clearly in FIG. 6. The taper at the end of the diaphyseal plate 40permits the remainder of the diaphyseal plate and the stem 14 of the endplate 10 to have substantially the same width, e.g., approximately 0.43″for a distal radius fixation system. It is noted that both ends 42, 44of the diaphyseal plate preferably have the same shape and features.Thus either end 42, 44 may be inserted into the slot 26 of the plate.

FIG. 6 shows the end 42 of the plate 40 inserted into the slot 26 of theplate 10. The tapered and rounded end 42 of the plate 40 is shaped anddimensioned to fit neatly into the slot 26 through the bottom of thevolar plate 10 with the threaded set screw hole 58 of the plate 40aligning with the unthreaded set screw hole 28 of the plate 10. When thetwo plates are arranged as shown in FIG. 6, a set screw 80 is insertedinto the hole 28 as shown in FIG. 7. When so inserted, the set screw 80is threaded into the threaded set screw hole 58 in the plate 40. Thissecures the two plates together so that they function as a single piece.It is an important aspect of the invention that the distal radius plateand diaphyseal plate be joined without reliance on the bone to jointhem. Otherwise, the tight interface and coupling between the platescould be compromised based on the quality of the bone, e.g., where suchbone is fractured beneath the location of the coupling or where the boneis osteoporotic.

The set screw 80 has a frustoconical head 82 from which depends athreaded stem 84. The head 82 has a hex socket 86 adapted to receive adriver (not shown). The set screw provides a secure lock between the twoplates independent of the bone.

By having a threaded set screw hole 58, 68 located near each end of thediaphyseal plate, each such hole can be used to lock the diaphysealplate to the volar plate, or may alternatively be used to lock anadjacent bone screw in a bone screw hole 46, 56 in place.

In accord with the invention, the end plate 10 at the slot 26 and thediaphyseal plate 40 are substantially similar in thickness, preferablywithin approximately 30% of each other, and more preferablyapproximately 26% (end plate=0.145″ and diaphyseal plate=0.115″). Therelatively close thicknesses are possible, for one reason, in that theend plate does not need to support the compressive forces of bone screwsat that location. Rather, as discussed above, the set screws used exerta substantially smaller force on the upper thinner portion of the endplate than would a cortical screw under compressive load.

It is appreciated that the end plate and diaphyseal plate components,separately machined or otherwise formed from each other, will invariablydiffer, within tolerances, from their specified designs. Such variationsfrom predefined dimensions may cause the components when assembled tohave some ‘play’. Any play between the components reduces the ability ofthe assembly to transfer load from one component to the other. Play alsoresults in micromovement of the components that may hamper the healingprocess. In view of the above, the second and third embodiments areprovided.

Turning now to FIGS. 9 through 14, the second embodiment of a modularplate system, including an end plate 110 and a diaphyseal plate 140, isshown. The end plate 110 includes stem portion 114 that is larger inwidth and thickness at a free end opposite the head portion 112. Theunderside of the free end 115 is open defining a socket in the form of acavity 126 into which a post 128 descends. The surface 129 from whichthe post descends is flat. The cavity 126 tapers in width and defines atan end a portion 130 stepped down in width. The end portion definesopposing flat parallel wall portions 131 a, 131 b. The stem portion 114includes a slightly oval set screw hole 132 into the cavity, locatedbetween the post 128 and the stepped down portion 130 of the cavity. Thecenters of the post 128 and set screw hole 132 are intended to be offsetby a first distance within a defined tolerance. An oval cortical bonescrew hole 134 is also provided in the thinner portion of the stem.

The diaphyseal plate 140 is similar to plate 40, but includes ends 145stepped down in width and sized to fit within the stepped down portion130 of the cavity 126. Such ends 145 include short opposing parallelflat sides 147 a, 147 b. In addition, the upper surface 150 of thediaphyseal plate over the last threaded set screw hole 146 and bonescrew hole 158 (i.e., that portion that will be received within thecavity, as described below) is flat to seat stably against flat surface129 in the cavity. The last set screw hole 146 and bone screw hole 158are offset from each other by a second distance within a definedtolerance. The second distance is slightly larger than the first defineddistance. Also, as an option, several of the screw holes, e.g., 160(FIG. 9), along the diaphyseal plate are non-locking oblong corticalscrew holes.

The set screw 180 includes a head 182 and a shank 184. Head 182 definedby two frustoconical sections: the upper frustoconical section 182 a isangled to seat against the rim 132 a of the set screw hole 132, whereasthe lower frustoconical section 182 b is angled to seat within the upperportion 146 a of the set screw hole 146 at the end of the diaphysealplate.

Referring to FIGS. 13 and 14, in assembly, an end 145 of the diaphysealplate is positioned with the cavity 126 of the end plate 110 and thepost 128 is inserted into bone screw hole 158 such that it extendstransverse to the longitudinal axis L_(A). Given the differences betweenthe first and second defined offset distances, the threads of set screwhole 146 do not perfectly align with the center of non-threaded setscrew hole 132. However, the shank 184 of the set screw 180 is easilymaneuvered through set screw hole 132 and into engagement within thethreads of the screw hole 146. As the upper section 182 a of the head182 contacts the rim 132 a of screw hole 132, the set screw 180 providesa force to push the post 128 of the end plate 110 against the diaphysealplate (at 190) causing significant interference so as to remove anyplay. As a result, in axial load, all force is transferred from the endplate to the diaphyseal plate. In addition, when the end plate issubject to torsional force, the flat sides 147 a, 147 b of thediaphyseal plate being in close contact with flat walls 131 a, 131 blimits rotation of the components relative to each other. The walls 131a, 131 b are of sufficient length to accommodate the range of tolerancesto which the components may be manufactured; i.e., so that flat sides147 a, 147 b are always adjacent some portion of the flat walls 131 a,131 b.

Turning now to FIGS. 15 through 20, the third embodiment of a modularplate system, including an end plate 210 and a diaphyseal plate 240, isshown. The end plate 210 is substantially similar to end plate 110, withthe following differences. The enlarged free end includes a widthwisetapered cavity 226 provided with a post 228, and two slightly oblongnon-threaded set screw holes 232, 233 entering the cavity 226 one oneither side of the post 228. Post 228 and screw hole 232 are offset by afirst distance within a defined tolerance. The thinner portion of theend plate includes a preferably oblong non-threaded bone screw hole 234.

The diaphyseal plate 240 is similar to plate 140 with the followingdifferences. The ends 245 are tapered and rounded and do not include thestepped end. The last set screw hole 246 and bone screw hole 258 areoffset from each other by a second distance within a defined tolerance.Another machine threaded screw hole 260 is provided independent of acooperative non-threaded bone screw hole. The screw hole 260 ispreferably defined by two spaced apart cantilevers 262, 264 set off fromthe interior of the plate by slots 266, 268 extending generally parallelto the longitudinal axis of the plate. In addition, a recess 270 isprovided at the upper portion of the screw hole 260.

Referring to FIGS. 19 and 20, in assembly, an end 245 of the diaphysealplate is positioned with the cavity 226 of the end plate 210 through thebottom of the end plate and the post 228 is inserted into bone screwhole 258. Given the differences between the first and second definedoffset distances, the threads of set screw hole 246 do not perfectlyalign with the center of non-threaded set screw hole 232. However, theshank 284 a of the set screw 280 a is easily maneuvered through setscrew hole 232 and into engagement within the threads of the screw hole246. As the upper section 282 a′ of the head 282 a contacts the rim 232a of screw hole 232, the set screw 280 a provides a force to push thepost 228 of the end plate 210 against the diaphyseal plate (at 290)causing significant interference so as to remove any play. As a result,in axial load, all force is transferred from the end plate 210 to thediaphyseal plate 240. The second set screw 280 b is inserted into screwhole 233. When set screw 280 b is fully seated, the chamfer at the lowerside of head portion 282 b′ contacts the chamfer about screw hole 233regardless of the position of the end plate 210 relative to thediaphyseal plate 240. Thus, when the end plate 240 is subject totorsional force, screw 280 b limits rotation of the components relativeto each other.

In one exemplar embodiment, the end plate 210 at the socket 226 has athickness of approximately 0.17″ and the diaphyseal plate 240 has athickness of 0.135″ at the portion positioned within the socket. Assuch, in accord with the first embodiment, the thickness of the couplingis less than approximately 30 percent and approximately 26 percent. Thesecond embodiment can be constructed with similar relative dimensions.

In addition, referring to FIG. 15, the end 245 a of the diaphyseal plate240 which is not coupled to the end plate 210 also includes a machinethreaded screw 260 a, as described above with respect to 260. Such screwhole 260 a and the associated framelike structure of the platethereabout decreases the rigidity of the plate at that location. Assuch, any cortical screw implanted into bone at the end 245 a, and thebone thereabout, will be subject to reduced maximum stress. In addition,the end 245 a of the plate can be adjusted in rigidity. By inserting aset screw or other insert into screw hole 260 a the diaphyseal plate ismade more rigid. Recess 270 allows countersinking of the head of suchset screw. For example, without the set screw the plate may have aflexibility of 0.003 inch, whereas with the set screw inserted, theflexibility is reduced to 0.001 inch. It is appreciated that in somecircumstances it is desirable to have a diaphyseal plate that isflexible at its ends, while in other instances, e.g., when the fractureis more comminuted, it is advantageous to have a plate that is lessflexible during the healing process. In addition, assuming that acomminuted bone fracture completely heals after a period of time, it maybe advantageous to have a plate that after healing allows the bone tofunction under normal conditions and does not produce high stressconcentrations at the cortical screw-bone interface. As such, the setscrew or insert can be bio-absorbable, maintaining needed fixationduring the healing process, followed by absorption such that the platehas higher stiffness during healing and is more flexible thereafter. Theresultant plate system would be less likely to result in refracture dueto the weakening attributed with drilling holes in the bone and thenpoint loading at those holes. Diaphyseal plates with such cantileveredset screw holes can be used with or without a modular end plate toachieve the benefits described above.

Referring now to FIGS. 21 through 23, a fourth embodiment of a distalradius modular fixation system, substantially similar to the thirdembodiment, is shown. The system includes a modular metaphyseal endplate 310 and a diaphyseal plate 340. The end plate 310 is preferablythe same as end plate 210 with the following difference. Screw hole 333,instead of being oblong (as is hole 233), is a countersunk chevron (orrounded triangular) shape. In a preferred embodiment, chevron hole 333includes three faces 402, 404, 406 defined by a generally 60° triangle.The faces 402, 404 are directed away from the head portion 316 of theend plate and provide two lateral points of contact 402 a, 404 a betweenthe conical flat head 382 a of the distal modular set screw 380 a andthe end plate 310. During coupling of the end and diaphyseal plates 310,340, in addition to downward compression, the head 382 a of the distalset screw 380 a imparts laterally opposing force at contact points 402a, 404 a about the longitudinal symmetry plane A_(L) (FIG. 23). Inaddition, because of the angular orientation of the contact faces 402,404, the head 382 a of the distal set screw also imparts a longitudinalforce along the symmetry plate A_(L). Alternately, the chevron hole 333could be reversed in direction such that contact surfaces 402, 404 aredirected toward the head portion 316 of the end plate.

Turning now to FIGS. 24 through 29, an embodiment of a proximal humeralmodular fixation system is shown. The system includes a proximal humeralmetaphyseal modular end plate 510 and a diaphyseal plate 540.

Referring to FIG. 24, the diaphyseal plate 540 includes features similarto plate 240. Plate 540 includes two end portions 545 each with sides547, 549 tapering at preferably approximately 6°. Each end portion 545preferably includes in the following order from its end: (i) acombination of a set screw hole 546 and bone screw hole 558, (ii) afirst cantilevered screw hole 560 (similar to hole 260) provided with anupper countersink recess 570, (iii) an oblong screw hole 572, (iv) asecond cantilevered screw hole 574, and (v) a second combination of aset screw hole 576 and a bone screw hole 578. Bone screw holes 558, 578are preferably non-threaded and also structured to receive corticalscrews in a fixed angle orientation substantially perpendicular to thebone contacting surface 580 of the plate. Other screw holes and K-wireand suture holes are also preferably provided along the length of thediaphyseal plate.

Referring to FIG. 25, the humeral end plate 510 includes a head portion512 preferably provided with threaded holes 514, fixed angle K-wireholes 516, and suture holes 518, as described in previously incorporatedU.S. Ser. No. 11/466,905. The end plate also includes a stem portion520. The head portion 512 is angled relative to the stem portion 520such that the bone contacting surface 522 of the head portion is angledupward at approximately 10°-18°, and most preferably approximately 15°,relative to the bone contacting surface 524 or long axis of the stemportion providing the head portion and stem portion each insubstantially parallel alignment relative to the underlying anatomy whenproperly positioned at the proximal humerus. The stem portion 520includes a lower socket (or recess) 526 for receiving the end portion545 of the diaphyseal plate 540. The socket 526 tapers in width atapproximately 6° to correspond to the tapered sides at the end portion545. The socket 526 defines a proximal undercut 527 to receive the endof the diaphyseal plate. An integrated post 528 extends downward fromthe top of the plate into the socket 526 for alignment within thecountersink recess 570 of the first cantilevered screw hole 560 of thediaphyseal plate, as described in more detail below. A first (middle)slightly eccentric tapered set screw hole 581 is provided for alignmentover the second cantilevered screw hole 574. Passing holes 582, 583sized to permit passage of a cortical screw completely therethrough andinto the bone screw holes 558, 578 in the diaphyseal plate 540 areprovided in alignment therefor, and second and third tapered holes 584,585 are provided adjacent the passing holes and in alignment with setscrew holes 546, 576. An oblong screw hole 586 is provided for alignmentover oblong screw hole 572 in the diaphyseal plate.

Referring to FIGS. 25 through 27, in assembly, an end 545 of thediaphyseal plate 540 is positioned into the socket 526 through thebottom of the end plate 510 with the post 528 inserted into the recess570 at the top of the first cantilevered screw hole 560. The end of thediaphyseal plate 540 seats within the undercut 527 defined at theproximal end of the socket 526. A set screw 587 is then inserted intothe first tapered set screw hole 581 and preliminarily engaged withinthe second cantilevered threaded screw hole 574 therebeneath thusdefining three points of contact to stabilize the assembly, as follows.A first point of contact 588 is defined between the end of thediaphyseal plate 540 and its contact with the socket 526 adjacent theundercut 527. A second point of contact 590 is defined between the post528 and the proximal side of recess 570. A third point of contact 592 isdefined between the head of set screw 587 and the distal side of taperedeccentric screw hole 581. Referring to FIG. 26, while these three pointsstabilize the assembly, it is appreciated that initially there may begaps between the tip of the diaphyseal plate and the undercut (at 594)and between the tapered sides of the diaphyseal plate and the taperedrecess (at 596). However, as shown in FIGS. 28 and 29, as the set screw587 is driven into the second cantilevered hole 574, the force of thetapered head of the set screw against the tapered surface of the screwhole 581 drives the two plates 510, 540 relative to each other toeliminate the gaps 594, 596 shown in FIGS. 26 and 27. The result is avery rigid assembly which transfers force from the end plate to thediaphyseal plate. Thus, with a single set screw the two plates are heldtogether such that the modular plate assembly can be positioned on thebone prior to the introduction of any cortical screws.

Referring to FIG. 29, after positioning the modular assembly on thebone, a hole is drilled for a multidirectional cortical screw 598 to beinserted through vertically offset oblong screw holes 572, 586. Hole 586is sized to capture the head of screw 598 such that the screw head isheld within hole 586 on the stem 520 of the humeral end plate 510. Theoblong shape of the hole 586 allows the modular assembly to be shiftedlongitudinally under the head of the screw 598 until the screw istightened to fix the location of the assembly on the bone. Screw holesare then drilled through passing holes 582, 583 and aligned with screwholes 558, 578, and fixed angle cortical screws 600, 602 are insertedthrough the screw holes into the bone. The heads of the cortical screws600, 602 pass through passing holes 582, 583 and are captured by thescrew holes 558, 578, providing further compression of the diaphysealportion of the modular assembly against the diaphysis of the bone. Setscrews 604, 606 are finally inserted into holes 546, 576 and underlyingset screw holes 584, 585 (but preferably do not interfere or extend intothe underlying bone), further coupling the end and diaphyseal platestogether in a manner which is independent of the bone and alsopreventing potential backout of the cortical screws 600, 602.

According to an important aspect of the invention, the plates 10 (110,210, 310, 510) and 40 (140, 240, 340, 540) are arranged in a kitcontaining several different size plates 10 and several different sizediaphyseal plates 40. According to the presently preferred embodiment,three different size volar plates are provided: standard, wide, andnarrow. The volar plate and humeral plates are also provided in left andright versions. A plurality of different length diaphyseal plates arealso provided. The diaphyseal plates may be straight or curved. Forexample, the plate may be curved in the plane of the plate to match theradius of curvature of the volar side of the radius bone, e.g., r=23inches over approximately eighty percent of the length of the plate. Thediaphyseal plates can be used alone or in combination with themetaphyseal end plates. When used together, distal and mid-shaftfractures can be covered with one integrated plate (e.g., the two platescoupled to each other as shown in FIG. 7 or 25). Thus, the loads areshared by the combined plate rather than the bone between two plates.The load is thereby spread out rather than concentrated on the bonebetween two plates. The modularity of the different size plates allowsfor the assembly of a wide variety of combinations using only a fewdifferent sizes. By way of example, and not by limitation, threedifferent width volar plates packed together with five different lengthdiaphyseal plates can be used to construct fifteen different sizecombination plates using only eight different size pieces. Similaradvantage can be provided in a humeral or other bone system.

According to an alternate embodiment of the invention, the metaphysealend plate is not required to include a socket in the form of a slot orcavity for receiving an end portion of the diaphyseal plate. Rather, adiscrete coupler with sockets at two of its sides can be providedbetween the end and diaphyseal plates. The coupler operates to “splice”together the metaphyseal end plate and the diaphyseal plate. Theadvantage is that the metaphyseal end plate for use in the system can bea standard component without modification, and can therefore be usedalone without the diaphyseal plate. Thus, the surgical tray will needfewer of the more expensive volar plates. In addition, the couplerallows “splicing” of multiple diaphyseal plates together to make oneextra long plate.

There have been described and illustrated herein embodiments of afixation plate, and particularly plates for fixation of distal radiusand proximal humerus fractures. While particular embodiments of theinvention have been described, it is not intended that the invention belimited thereto, as it is intended that the invention be as broad inscope as the art will allow and that the specification be read likewise.Thus, while particular preferred materials, dimensions, and relativeangles for particular elements of the system have been disclosed, itwill be appreciated that other materials, dimensions, and relativeangles may be used as well. Further, while the invention has beendescribed with respect to distal volar radius and proximal humerusplates, the invention may include other ‘end’ plates suitable in sizeand shape for placement at other metaphyseal locations, e.g., the dorsalside of the distal radius, the femur and the tibia. In addition, endplates of shapes other than described may also be used, such as lateraland medial columns (generally ‘L’-shaped), and plates having a flared orforked head, provided such end plates are dimensioned and configured forplacement at the metaphysis. In addition, while a particular number ofscrew holes in the end plate and diaphyseal plate have been described,it will be understood a different numbers of screw holes may be used.Also, fewer or more threaded holes (for pegs or locking screws) may beused. In addition, while particular preferred angles between the headand stem or shaft of the end plates have been disclosed, other anglescan also be used. Further, while various connection structures betweenthe end plate and diaphyseal plate have been disclosed, it isappreciated other connection structures can be used as well. That is,provided that a rigid assembly can be maintained, for example, withthree points of contact, the post can be eliminated, and the variousscrew holes can be re-arranged, reconfigured, or altered in number.Also, while the term diaphyseal plate has been used for platesstructured and intended for placement on the diaphysis of a long bone,the term is also intended to encompass any fragment plate structured forplacement on a long bone and intended for coupling with a metaphysealend plate in a manner claimed. It will therefore be appreciated by thoseskilled in the art that yet other modifications could be made to theprovided invention without deviating from its scope.

What is claimed is:
 1. A method of coupling a plurality of bone platesto a bone, comprising: a) first coupling first and second platestogether separately from the bone with a set screw such that the firstand second plates are securely longitudinally retained in tension,independently of the bone, wherein axial advancement of said set screwinto said plates in a first direction causes movement of said first andsecond plates relative to each other in a direction perpendicular to thefirst direction; b) attaching the coupled first and second plates to thebone with a first cortical screw, the first cortical screw having a headthat seats on the first plate; and c) further securing said coupledplates to the bone with a second cortical screw, said second corticalscrew having a head that passes through the first plate and seats on thesecond plate.
 2. A method according to claim 1, wherein: said firstcoupling includes inserting one end of the first plate into a socket inthe second plate.
 3. A method according to claim 1, further comprising:altering a rigidity of the second plate during said first coupling.
 4. Amethod according to claim 1, wherein: after securing the coupled platesto the bone, further coupling the plates together with elements that donot extend into bone.
 5. A method according to claim 4, wherein: saidfurther coupling prevents backout of the first and second corticalscrews.
 6. A method according to claim 1, wherein: the first plate is aproximal metaphyseal humeral plate and the lower plate is a humeraldiaphyseal plate.
 7. A method according to claim 1, wherein: said firstand second plates are longitudinally retained in tension along alongitudinal direction, and said direction perpendicular to the firstdirection is said longitudinal direction.
 8. A method of coupling aplurality of bone plates to a bone, comprising: coupling first andsecond plates together separately from the bone with a set screw suchthat they are securely longitudinally retained in tension, independentlyof the bone, wherein axial advancement of said set screw into saidplates in a first direction causes movement of said first and secondplates relative to each other in a direction perpendicular to the firstdirection; and then securing said coupled plates to the bone with a bonescrew, said bone screw having a head that passes through the first plateand seats on the second plate and a shaft with bone engaging threads. 9.A method according to claim 8, wherein: said first coupling includesinserting one end of the first plate into a socket in the second plate.10. A method according to claim 8, wherein: after securing the coupledplates to the bone, further coupling the plates together with elementsthat do not extend into bone.
 11. A method according to claim 10,wherein: said further coupling prevents backout of the bone screw.
 12. Amethod according to claim 8, wherein: the first plate is a proximalmetaphyseal humeral plate and the second plate is a humeral diaphysealplate.
 13. A method according to claim 8, further comprising: beforesaid securing, attaching the coupled first and second plates to the bonewith a bone screw, the bone screw having a head that seats on the firstplate and a shaft with bone engaging threads that passes through thesecond plate.
 14. A method according to claim 8, wherein: said first andsecond plates are longitudinally retained in tension along alongitudinal direction, and said direction perpendicular to the firstdirection is said longitudinal direction.
 15. A method of coupling aplurality of bone plates to a bone, comprising: providing first andsecond plates, each of said first and second plates having respectivebone contacting portions; coupling the first and second plates togetherseparately from the bone with a set screw such that they are securelylongitudinally retained in tension independently of the bone, whereinaxial advancement of said set screw into said plates in a firstdirection causes movement of said bone contacting portions of said firstand second plates relative to each other in a second directionperpendicular to the first direction; and then securing said coupledplates to the bone with a bone screw.
 16. A method according to claim15, further comprising: after securing the coupled plates to the bone,further coupling the plates together with an element that does notextend into bone.
 17. A method according to claim 15, wherein: said bonescrew has a head that passes through the first plate and seats on thesecond plate and a shaft with bone engaging threads.
 18. A methodaccording to claim 15, wherein: said first direction is parallel to alongitudinal direction of said first and second plates.
 19. A method ofcoupling a plurality of bone plates to a bone, comprising: providing aselection of first-type of plate and second-type of plate, the selectionof said first-type and second-type of plates including discrete sizes ofat least one of said respective types of plates; first coupling aselected first-type and second-type of plates together separately fromthe bone with a set screw such that they are securely longitudinallyretained in tension, independently of the bone, wherein axialadvancement of said set screw into said plates in a first directioncauses movement of said first and second plates relative to each otherin a direction perpendicular to the first direction; and then securingsaid coupled plates to the bone with a bone screw, said bone screwhaving a head that passes through the first-type of plate and seats onthe second-type plate and a shaft with bone engaging threads.
 20. Amethod according to claim 19, wherein: axial advancement of said setscrew into said plates in a first direction causes movement of saidplates relative to each other in a direction perpendicular to the firstdirection.
 21. A method according to claim 19, wherein: said firstcoupling includes inserting one end of the first-type of plate into asocket in the second-type of plate.
 22. A method according to claim 19,wherein: after securing the coupled first-type and second-type plates tothe bone, further coupling the plates together with an element that doesnot extend into bone.
 23. A method according to claim 22, wherein: saidfurther coupling prevents backout of the bone screw.
 24. A methodaccording to claim 19, wherein: said set screw causes movement of saidfirst and second plates relative to each other in a longitudinaldirection.
 25. A method according to claim 19, wherein: said set screwcauses movement of said first and second plates relative to each otheralong a longitudinal axis of one of said first and second plates.
 26. Amethod of coupling a plurality of bone plates to a bone having afracture, comprising: providing first and second plates; coupling thefirst and second plates together separately from the bone with a setscrew such that they are securely longitudinally retained in tensionindependently of the bone, wherein axial advancement of said set screwinto said plates in a first direction causes movement of said first andsecond plates relative to each other in a direction perpendicular to thefirst direction; then securing said first of said coupled plates to thebone on one side of the fracture with a first bone fastener; and then,without disassembling said coupled first and second plates from eachother, coupling said second of said coupled plates to the bone on theother side of the fracture with a second bone fastener.